Please enter your Patient ID
To what extent do you suffer from excessively dry skin or hair?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
Is your skin becoming thin?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from dry eyes?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from feeling cold or a low body temperature?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from unexplained hoarseness?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from recent frequent, intense headaches?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from abdominal fluid retention?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from urinary incontinence?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from painful intercourse?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you experience a lack of interest in sex?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent have you felt a decrease in your level of sexual sensation?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from cold extremities?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from fluid retention (edema)?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from a decrease in your physical stamina?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from chronic fatigue?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from difficulty with memory or recall?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from night sweats?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from anxiety?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from lack of interest in life (apathy)?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from difficulty with concentration and focus?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from a depresssed mood?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from emotional irritability?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from mood swings?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from difficulty staying asleep?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from unexplained weight gain or difficulty controlling your weight?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you struggle with hair loss or hair thinning?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from breast tenderness?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from hot flashes?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you suffer from vaginal dryness?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely
To what extent do you struggle with muscle pain or chronic pain?
Not at all/Unsure
Very Minimally
Mildly
Moderately
Significantly
Severely